Managing Chronic Disease in Affordable Primary Care

National agencies are calling for quality improvement in primary care health care services and across the United States health care system. Changes would be directed toward improving quality of life for the chronically ill and decreasing their financial burden and that placed on society. Nurse practitioners, based on their expertise and preparation in patient education, are ideal health care providers to establish partnerships with motivated, informed, chronically ill patients and to promote change in health care policy, guidelines, and meeting patient educational needs. Within worksite primary care, nurse practitioners can, through the Chronic Care Model framework, provide chronic disease management and affordable health care access.     

口腔科患者电子病历程序的建立

目的通过系统结构设计、专家指标论证等方式,建立起有循证医学意义的口腔疾病病案管理系统框架图和口腔科患者病案管理系统的电子程序。方法使用模拟退火模型收录可能的诊断指标、治疗指标、复查指标,使用9分度专家打分法分别建立三个指标的层次分析模型,对于三个指标进行分层,并运用ACCESS+ASP技术构建网络框架体系。结果设计出的口腔科电子病历管理网站可包涵四大业务模块:面向患者模块;面向医生模块;费用管理;数据模块。结论口腔门诊电子病历管理网站的建立能很好地保证病案的完整性,系统地进行口腔疾病统计,促进口腔医患互动和圈内病例的交流学习。     

Rethinking the Barcelona clinic liver cancer guidelines: Intermediate stage and Child-Pugh B patients are suitable for surgery?

According to Barcelona Clinic Liver Cancer recommendations, intermediate stage hepatocellular carcinomas (stage B) are excluded from liver resection and are referred to palliative treatment. Moreover, Child-Pugh B patients are not usually candidates for liver resection. However, many hepatobiliary centers in the world manage patients with intermediate stage hepatocellular carcinoma or Child-Pugh B cirrhosis with liver resection, maintaining that hepatic resection is not contraindicated in selected patients with non–early-stage hepatocellular carcinoma and without normal liver function. Several studies demonstrate that resection provides the best survival benefit for selected patients in very early/early and even in intermediate stages of Barcelona Clinic Liver Cancer classification, and this treatment gives good results in the setting of multinodular, large tumors in patients with portal hypertension and/or Child-Pugh B cirrhosis. In this review we explore this controversial topic, and we show through the literature analysis how liver resection may improve the short- and long-term survival rate of carefully selected Barcelona Clinic Liver Cancer B and Child-Pugh B hepatocellular carcinoma patients. However, other large clinical studies are needed to clarify which patients with intermediate stage hepatocellular carcinoma are most likely to benefit from liver resection.     

Screening for genetic haemochromatosis in a rheumatology clinic

Background: Recent data indicate that the prevalence of genetic haemochromatosis (GH) is greater than previously recognised and suggest that this disease is underdiagnosed. Aims: To determine the prevalence of GH in a rheumatology clinic population. Methods: Over a 12 month period 339 consecutive patients, mean age 67.0 years, attending a rheumatology clinic were screened for iron overload. Results: Twenty three patients had elevated initial screening tests (transferrin saturation [Tf %] > 55% ferritin > 500 μg/L). Repeat fasting Tf % and ferritin concentrations were obtained in 20 of these patients. Twelve patients had persistently elevated results, and of these patients four had liver biopsy tissue hepatic iron indices consistent with GH. One patient in the group had the diagnosis established by liver biopsy just before the screening commenced. Thus, the prevalence of GH in this population was 1.5% - five times that anticipated for the general population. Three of the patients with GH presented with an arthropathy which was not characteristic of the disease. The increased prevalence of GH in this group of patients with peripheral arthropathy provides an excellent justification for the routine screening of patients with peripheral arthritis for the exclusion of iron overload.     

Radionuclide analysis of peak filling rate, filling fraction, and time to peak filling rate. Response to supine bicycle exercise in normal subjects and patients with coronary disease

Using gated equilibrium radionuclide angiography, variables of diastolic filling were analyzed at rest and during supine bicycle exercise in normal subjects (Group 1, n = 18), coronary patients with normal resting ejection fractions (Group 2, n = 26), and coronary patients with reduced resting ejection fractions (Group 3, n = 8). Indexes analyzed were peak filling rate and filling fraction during the first third of diastole. At rest, the peak filling rate was significantly lower in coronary patients than in normal subjects (3.18 +/- 0.82 end-diastolic volume [EDV]/s in Group 1 versus 2.41 +/- 0.66 EDV/s in Group 2, p less than 0.005; and 1.34 +/- 0.26 EDV/s in Group 3, p less than 0.001 versus Group 1). These differences persisted at peak exercise. Coronary patients also had significantly lower filling fractions at rest and during exercise than did normal control subjects. The time from end-systole to peak filling rate was longer at rest in patients in Group 2 (203 +/- 52 ms) than in subjects in Group 1 (172 +/- 50 ms, p less than 0.025). This remained true when the time to peak filling was normalized by the R-R interval. Although the exercise time to peak filling was longer in coronary patients in both Groups 2 and 3 than in Group 1, these differences were not apparent when the interval was normalized by the R-R interval. Thus, abnormalities in peak filling rate and filling fraction exist in patients with coronary disease both at rest and during exercise, but large overlaps exist between normal and coronary patients. Caution is advised in comparing the timing of events during diastole because apparent group differences may be related in part to rest or exercise heart rate.     

Baroreflex dysfunction in patients with adult-onset diabetes and hypertension

Ten patients with adult-onset diabetes in whom diabetes antedated the appearance of hypertension were evaluated. These patients had evidence of diabetic autonomic neuropathy, including significant orthostatic hypotension (four patients), impotence (three patients), and evidence of diabetic peripheral sensorimotor neuropathy (nine patients) in clinical testing and nerve conduction study results. Baroreflex function was evaluated by multiple hemodynamic tests, including inhalation of amyl nitrite and intravenous administration of phenylephrine, before and after parasympathetic blockade with atropine, and the cold presser test; results were compared with results in normal control subjects, patients with essential hypertension, and two subgroups of uremie patients undergoing maintenance hemodialysis. Baroreflex function was significantly abnormal in the diabetic patients and was consistent with combined parasympathetic and sympathetic motor nerve (efferent) dysfunction in the baroreflex arc. There was a significant inverse correlation between the degree of orthostatic hypotension in the diabetic patients and their baroreflex responsc to phenylephrine (r = ?0.680, p < 0.05). There was no significant correlation between supine hypertension in the patients with diabetes and any of the hemodynamic or biochemical parameters examined. The results suggest that orthostatic hypotension in these patients is related to baroreflex dysfunction. However, baroreflex dysfunction does not appear to be a factor in the development of hypertension in these patients, although more studies with normotensive diabetic patients are needed to confirm this point.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

《内经》五郁之治在儿科临床中的应用

《内经》五郁之治,是针对五气太过而致五脏气郁所提出的治疗法则,从五郁治法概述以及相应木郁达之、火郁发之、土郁夺之、金郁泄之、水郁折之五法进行了理论阐释和临床运用举例。指出五郁之治不仅适用于内科常见病证的辨治,对于儿科临床常见病证的辨治亦有很好的指导意义。     

基于思维导图的培训在儿科门诊护士心肺复苏教学中的应用效果

目的:探讨基于思维导图的培训在儿科门诊护士心肺复苏教学中的应用效果。方法:选取2019年1月—2019年12月医院儿科门诊43名护理人员为研究对象,随机将其分为对照组21人和观察组22人,对照组采用常规培训方法进行心肺复苏教学,观察组采用基于思维导图的培训方法进行心肺复苏教学。比较两组护理人员培训后复苏理论知识、复苏技能及临床综合能力的变化。结果:培训后观察组儿科门诊护理人员心肺复苏理论成绩、心肺复苏按压技能、正压通气技能、电除颤操作技能评分均高于对照组(P<0.05),培训后观察组儿科门诊护理人员心肺复苏知识运用及理解能力、分析问题能力、评判性思维能力、临床与实践结合能力、自主学习能力及临床综合能力评分高于对照组(P<0.05)。结论:基于思维导图的培训不仅能提高儿科门诊护理人员心肺复苏知识及技能水平,同时有助于儿科护理人员综合急救能力的培养,进而提高心搏骤停患儿心肺复苏的成功率。     

助产士主导的连续照护服务模式的应用研究

目的:探讨在助产士门诊实施助产士主导的连续照护服务模式对母儿的影响。方法:选取2019年6月—2020年6月的绿色层级低危初产孕妇380例为试验组,黄色层级一般风险管理的单一合并症初产孕妇310例,助产士门诊根据孕产妇妊娠风险评估情况,对绿色层级低风险初产孕妇采用助产士一对一个性化全程连续照护结合黄色层级一般风险初产孕妇(孕期体质指数异常、妊娠期铁缺乏和妊娠期合并缺铁性贫血、妊娠期糖尿病、乙型肝炎感染)采用助产士专组专案管理方式个性化全程连续照护。2018年5月—2019年5月在我院产科门诊建档按期产检分娩的绿色层级低危初产孕妇460例为对照组,黄色层级一般风险管理的单一合并症初产孕妇358例,对照组孕妇接受传统的产科医师主导的产前检查。比较两组孕产妇及母儿结局。结果:两组绿色层级低危初产孕妇在阴道试产率,阴道自然分娩率,会阴侧切率,非指证剖宫产率,孕妇及家属的满意度等比较差异有统计学意义(P<0.05);在会阴裂伤Ⅲ度及以上发生率、产后出血率、新生儿窒息率等方面比较差异无统计学意义(P>0.05)。两组黄色层级一般风险组单一合并孕期体质指数异常初产孕妇在妊娠28周,妊娠36周,分娩时的体质指数,新生儿出生体重,巨大儿及低体重儿发生率等方面比较差异有统计学意义(P<0.05);在妊娠12周的体质指数,新生儿窒息率等方面比较差异无统计学意义(P>0.05)。两组黄色层级一般风险组单一合并妊娠期铁缺乏或妊娠期缺铁性贫血的初产孕妇在入组干预2个月后血清铁水平、分娩时血清铁水平、产前输血率、知识知晓度、孕产妇及家属满意度等比较差异有统计学意义(P<0.05);在新生儿窒息率方面比较差异无统计学意义(P>0.05)。两组黄色层级一般风险组单一合并妊娠期糖尿病初产孕妇在剖宫产率、饮食控制佳、糖尿病相关知识知晓、新生儿出生后30 min低血糖发生率、分娩巨大儿比率等方面比较差异有统计学意义(P<0.05);在新生儿窒息发生率方面比较差异无统计学意义(P>0.05)。两组黄色层级一般风险组单一合并乙型肝炎感染初产孕妇在分娩时焦虑评分、42 d复查时焦虑评分、纯母乳喂养率、孕产妇及家属满意度等方面比较差异有统计学意义(P<0.05);在入组时焦虑评分方面比较差异无统计学意义(P>0.05)。结论:在助产士门诊实施助产士主导的连续照护服务模式可以降低非指证剖宫产率,提高合并症相关知识知晓度,控制病情稳定,提高孕产妇及家属的满意度。